Jack Peatling
PFD Report
All Responded
Ref: 2025-0510
Community health care and emergency services related deaths
Mental Health related deaths
Suicide (from 2015)
All 2 responses received
· Deadline: 5 Dec 2025
Coroner's Concerns (AI summary)
A chronic lack of available in-patient mental health beds for high-risk patients who cannot be safely managed in the community led to an avoidable suicide.
View full coroner's concerns
(a) A highly vulnerable 20-year-old man, with a history of anxiety, depression and impulsive previous suicide attempts made two further serious attempts to take his own life and inflicted an extensive wound to his arm after those suicide attempts were frustrated by his mother. The subsequent formal MHA assessment determined Jack to be such a high risk of suicide that an immediate period of assessment and treatment as a (voluntary) in-patient on an MHAU was required as his high risk of suicide could not be safely managed in the community. (b) No such bed was available over the six days between the MHA assessment and Jack’s suicide with still no indication, at the time of his death, as to if or when a bed would be available. By default, and notwithstanding point (a) above, the HTT, absent an in-patient bed, became responsible for his care in the community. (c) In his evidence, it was further expressly recognised by the HTT psychiatrist who saw Jack on the 31st May that his “very, very high risk” of suicide at that time could not be managed safely in the community by the HTT and, further, that Jack was “untreatable” in the community. (d) Nonetheless, and notwithstanding the unanimous clinical view, the non-availability of an EPUT MHAU in-patient bed meant that the HTT were required to attempt to mitigate this unmanageable level of risk in the community, something that the HTT was, as had been anticipated, unable to do. (e) The evidence confirmed that a lack of available in-patient beds for high-risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community, is a chronic and on-going situation in Essex and, the inquest was told, nationally. (f) Jack took his own life by deploying a ligature on the sixth day awaiting the necessary, required in-patient bed. Had an in-patient bed been made available, he would probably not have died. Jack’s death was avoidable. (g) Absent the provision of available mental health in-patient beds for very high-risk patients that formal Mental Health Act assessments have clinically determined cannot be managed safely in the community, then further avoidable deaths by suicide amongst this cohort of vulnerable patients appears inevitable.
Responses
Action Planned
NHS England is making £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements. The therapeutic acute inpatient operating model for adults and older adults, will be introduced. (AI summary)
NHS England is making £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements. The therapeutic acute inpatient operating model for adults and older adults, will be introduced. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Jack Mathew Peatling who died on 5th June 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13th October 2025 concerning the death of Jack Mathew Peatling on 5th June 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jack’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Jack’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Jack’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.
Your Report raised concerns that there were no inpatient mental health beds available for Jack despite him being determined as a high risk of suicide and unable to be managed safely in the community. You were concerned that this lack of bed availability is a chronic and ongoing issue nationally.
Mental Health Beds NHS England is aware of the issues in some systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
16th December 2025
However, given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. NHS England’s 2025/26 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds. NHS England is taking steps to address current operational pressures driving these issues. If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.
Essex Partnership University NHS Foundation Trust Essex Partnership University NHS Foundation Trust (EPUT) has advised that when there is insufficient capacity to meet all hospital admission demands, the Chair of the twice-daily situation report meetings is mandated to seek assurance that sufficient community mitigation and safeguards are in place to continue with community intervention as an alternative to admission. Furthermore, Home Treatment Teams (HTTs) are instructed to raise as a priority for admission those individuals for whom the HTT is unable to provide adequate mitigation and/or where there is an escalating risk presentation. If a patient's clinical need is escalated and indicates an urgent inpatient admission is required, and if there is insufficient mitigation to support a community alternative, a bed will be sourced. This commitment extends to actively scoping and securing out- of-area provision when local capacity is exhausted, ensuring that every effort is made to provide the necessary level of care. EPUT recognises that the lack of available inpatient beds for high-risk mental health patients, who cannot be managed safely in the community, is an ongoing challenge. They are committed to addressing this system-wide issue and preventing further avoidable deaths. Since the time of this incident, EPUT has implemented a series of significant changes aimed at improving patient flow, bed management and overall patient safety: Clinical Patient Flow Lead: They have introduced a clinical patient flow lead whose role is to review admission requests against bed demand and support clinical formulation and decision-making when prioritising beds.
Clinical Director in Flow and Capacity Team: A clinical director has been recruited to the flow and capacity team. This director is a Consultant Psychiatrist who reviews complex and high-risk cases, supports the prioritisation of beds against demand and provides oversight of patients in out-of-area beds. Surge Management Tool: A Surge Management Tool (SMART) has been implemented to support patient admission demand and repatriation. This platform provides a local and system-wide overview of operational pressures, enabling them to track patient flow between care settings, view current demand and capacity, and map all patient admission referrals and repatriations from a range of providers and services. Therapeutic Acute Inpatient Operating Model: A new, innovative operating model for inpatient care, the therapeutic acute inpatient operating model for adults and older adults, will be introduced. This model aims to provide consistent quality of care 24/7, integrated with place-based community models and the wider system. It is designed to enhance patient experience by working in partnership with patients and carers, reduce health inequalities and increase Trust capacity to provide high-quality therapeutic care. The model is informed by national and best practice guidance, developed by multi-professional clinicians, colleagues with lived experience, and wider system stakeholders. These changes detail EPUT’s commitment to learning from past incidents and to the continuous improvement of their systems and processes to ensure the safest possible care for patients. Should HM Coroner require any further detail, we would recommend contacting EPUT directly.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Jack, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 13th October 2025 concerning the death of Jack Mathew Peatling on 5th June 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jack’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Jack’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Jack’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.
Your Report raised concerns that there were no inpatient mental health beds available for Jack despite him being determined as a high risk of suicide and unable to be managed safely in the community. You were concerned that this lack of bed availability is a chronic and ongoing issue nationally.
Mental Health Beds NHS England is aware of the issues in some systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
16th December 2025
However, given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission. NHS England’s 2025/26 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds. NHS England is taking steps to address current operational pressures driving these issues. If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.
Essex Partnership University NHS Foundation Trust Essex Partnership University NHS Foundation Trust (EPUT) has advised that when there is insufficient capacity to meet all hospital admission demands, the Chair of the twice-daily situation report meetings is mandated to seek assurance that sufficient community mitigation and safeguards are in place to continue with community intervention as an alternative to admission. Furthermore, Home Treatment Teams (HTTs) are instructed to raise as a priority for admission those individuals for whom the HTT is unable to provide adequate mitigation and/or where there is an escalating risk presentation. If a patient's clinical need is escalated and indicates an urgent inpatient admission is required, and if there is insufficient mitigation to support a community alternative, a bed will be sourced. This commitment extends to actively scoping and securing out- of-area provision when local capacity is exhausted, ensuring that every effort is made to provide the necessary level of care. EPUT recognises that the lack of available inpatient beds for high-risk mental health patients, who cannot be managed safely in the community, is an ongoing challenge. They are committed to addressing this system-wide issue and preventing further avoidable deaths. Since the time of this incident, EPUT has implemented a series of significant changes aimed at improving patient flow, bed management and overall patient safety: Clinical Patient Flow Lead: They have introduced a clinical patient flow lead whose role is to review admission requests against bed demand and support clinical formulation and decision-making when prioritising beds.
Clinical Director in Flow and Capacity Team: A clinical director has been recruited to the flow and capacity team. This director is a Consultant Psychiatrist who reviews complex and high-risk cases, supports the prioritisation of beds against demand and provides oversight of patients in out-of-area beds. Surge Management Tool: A Surge Management Tool (SMART) has been implemented to support patient admission demand and repatriation. This platform provides a local and system-wide overview of operational pressures, enabling them to track patient flow between care settings, view current demand and capacity, and map all patient admission referrals and repatriations from a range of providers and services. Therapeutic Acute Inpatient Operating Model: A new, innovative operating model for inpatient care, the therapeutic acute inpatient operating model for adults and older adults, will be introduced. This model aims to provide consistent quality of care 24/7, integrated with place-based community models and the wider system. It is designed to enhance patient experience by working in partnership with patients and carers, reduce health inequalities and increase Trust capacity to provide high-quality therapeutic care. The model is informed by national and best practice guidance, developed by multi-professional clinicians, colleagues with lived experience, and wider system stakeholders. These changes detail EPUT’s commitment to learning from past incidents and to the continuous improvement of their systems and processes to ensure the safest possible care for patients. Should HM Coroner require any further detail, we would recommend contacting EPUT directly.
I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Jack, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Action Planned
The Department of Health and Social Care outlines plans to reduce mental health waiting times, improve management of bed capacity, and expand community mental health services. It has committed £26 million in capital investment to open new mental health crisis centres. (AI summary)
The Department of Health and Social Care outlines plans to reduce mental health waiting times, improve management of bed capacity, and expand community mental health services. It has committed £26 million in capital investment to open new mental health crisis centres. (AI summary)
View full response
Dear Mr Horstead
Thank you for your Regulation 28 report to prevent future deaths dated 13th October 2025 about the death of Jack Mathew Peatling. I am replying as the Minister with responsibility for mental health and patient safety and I am grateful for the additional time you have allowed for me to do so.
Firstly, I would like to say how saddened I was to read of the circumstances of Jack’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. I also understand that this tragic case is being considered as part of Lampard Inquiry – the independent statutory inquiry investigating the deaths of mental health inpatients in Essex between 2000 and 2023.
Your report raises concerns addressed to the Department regarding a lack of available in-patient beds for high-risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community. I note that NHS England have also provided a response and are aware of the issues in some systems around high bed occupancy and limited local bed availability which can be found here: 2025-0510 - Response from NHS England
I understand your concerns.
We are determined to bring mental health waiting times down and intervene earlier, so people get the right mental health support at the right time in the right place.
I expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.
The NHS Operational Planning Guidance for 2025-26 contains fewer targets across the board to focus on the fundamentals of good care. It sets a requirement for
Integrated Care Boards to take action to reduce the average length of stay in adult acute mental health beds, in order to improve local bed availability and reduce the need for inappropriate out of area placement. This involves making use of alternatives described below:
• Reducing avoidable ambulance dispatches and conveyances, and reduce handover delays by working towards delivering hospital handovers within 15 minutes, with joint working arrangements that ensure that no handover takes longer than 45 minutes and improving access to urgent care services at home or in the community including urgent community response and virtual ward (also known as hospital at home) services
• Improve and standardise urgent care at the front door of the hospital by increasing the proportion of patients seen, treated and discharged in 1 day or less using the principles of same day emergency care and optimising the urgent care offer to meet the needs of their local population, including the use of urgent treatment centres .
• Reduce length of stay in hospital and ensure that patients are cared for in the most appropriate setting by increasing the percentage of patients discharged by or on day 7 of their admission in line with existing guidance. Additionally, by working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework. ICBs should review BCF commitments to ensure they represent the best use of resources, and plan sufficient intermediate care capacity to meet demand, including through surge periods across the year.
Over the period 2026/27 to 2028/29, integrated care boards have been asked to drive real productivity gains including reducing the average length of stay in adult acute mental health beds, through the recently published Medium Term Planning Framework.
We have committed £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy emergency mental health and A&E services and ensuring people have the support they need when they need it.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Thank you for your Regulation 28 report to prevent future deaths dated 13th October 2025 about the death of Jack Mathew Peatling. I am replying as the Minister with responsibility for mental health and patient safety and I am grateful for the additional time you have allowed for me to do so.
Firstly, I would like to say how saddened I was to read of the circumstances of Jack’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. I also understand that this tragic case is being considered as part of Lampard Inquiry – the independent statutory inquiry investigating the deaths of mental health inpatients in Essex between 2000 and 2023.
Your report raises concerns addressed to the Department regarding a lack of available in-patient beds for high-risk mental health patients who, as was acknowledged at the time, cannot be managed safely in the community. I note that NHS England have also provided a response and are aware of the issues in some systems around high bed occupancy and limited local bed availability which can be found here: 2025-0510 - Response from NHS England
I understand your concerns.
We are determined to bring mental health waiting times down and intervene earlier, so people get the right mental health support at the right time in the right place.
I expect individual trusts and local health systems to effectively assess and manage local bed capacity through the ‘flow’ of patients being discharged or moving to another setting.
The NHS Operational Planning Guidance for 2025-26 contains fewer targets across the board to focus on the fundamentals of good care. It sets a requirement for
Integrated Care Boards to take action to reduce the average length of stay in adult acute mental health beds, in order to improve local bed availability and reduce the need for inappropriate out of area placement. This involves making use of alternatives described below:
• Reducing avoidable ambulance dispatches and conveyances, and reduce handover delays by working towards delivering hospital handovers within 15 minutes, with joint working arrangements that ensure that no handover takes longer than 45 minutes and improving access to urgent care services at home or in the community including urgent community response and virtual ward (also known as hospital at home) services
• Improve and standardise urgent care at the front door of the hospital by increasing the proportion of patients seen, treated and discharged in 1 day or less using the principles of same day emergency care and optimising the urgent care offer to meet the needs of their local population, including the use of urgent treatment centres .
• Reduce length of stay in hospital and ensure that patients are cared for in the most appropriate setting by increasing the percentage of patients discharged by or on day 7 of their admission in line with existing guidance. Additionally, by working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework. ICBs should review BCF commitments to ensure they represent the best use of resources, and plan sufficient intermediate care capacity to meet demand, including through surge periods across the year.
Over the period 2026/27 to 2028/29, integrated care boards have been asked to drive real productivity gains including reducing the average length of stay in adult acute mental health beds, through the recently published Medium Term Planning Framework.
We have committed £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy emergency mental health and A&E services and ensuring people have the support they need when they need it.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Sent To
- Department of Health and Social Care
- NHS England
Response Status
Linked responses
2 of 2
56-Day Deadline
5 Dec 2025
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 23rd June 2023 I commenced an investigation into the death of Jack Mathew Peatling, aged 20 years. The investigation concluded at the end of the article 2 (non-jury) inquest on the 10th October 2025. The Conclusion of the inquest was a Short Form Conclusion of Suicide in conjunction with an expanded Narrative Conclusion expressed (in summary) in the following terms: Jack Peatling’s death was directly contributed to by the non-availability of an in-patient bed in an EPUT Mental Health Assessment Unit. His very high level of risk of suicide had been determined by a formal Mental Health Act assessment to require an immediate period of assessment and treatment as in-patient with a recognition, in terms, that his risk of suicide was such that he could not be kept safe in the community. Jack spent six days at home awaiting a bed before taking his own life by the fatal deployment of a ligature.
Circumstances of the Death
On a background of diagnoses of anxiety and depression and historical attempts at suicide and repeated self-harm, Jack made two further serious attempts to take his own life, on the 29th May 2023. When his mother intervened and frustrated these suicide attempts, he inflicted a grave wound to his left arm Following a formal Mental Health Act (MHA) assessment at Basildon Hospital the following day, Jack’s (informal) admission to a Mental Health Assessment Unit (MHAU) was confirmed as urgent and necessary for appropriate assessment, management and treatment of his anxiety and depression and his impulsive suicide attempts. With the agreement of Jack and his mother, the assessment determined that in the context of his on-going very high level of risk of suicide, with high levels of impulsivity, Jack could not be safely managed in the community. Over the next 6 days the Essex Partnership University NHS Foundation Trust (EPUT) were unable to identify the required in-patient bed anywhere in Essex. Evidence confirmed that demand for such beds outstripped supply and that this had been and remained a chronic issue, locally and nationally. Attempts were made to manage Jack’s risk of suicide in the community with a single visit from a Home Treatment Team (HTT) Psychiatrist on the 31st May and then subsequent short daily visits to Jack at his family home by an HTT Community Psychiatric Nurse. It was acknowledged by the professionals involved in the MHA assessment itself, by the HTT clinicians and psychiatric nurses subsequently involved, as well as by Jack himself and his mother, that his risk of suicide could not be safely managed in the community. Accordingly, Jack’s death by suicide on June 5th 2023 was directly contributed to by the non-availability, over several days, of a bed in an EPUT MHAU in Essex.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
IPC role specifications and staffing levels
Scottish Hospitals Inquiry
Chronic healthcare staff shortages
Community mental health services for violence-fixated children
Southport Inquiry
Mental health access for alcohol addiction
Mental health assessment powers for isolated children
Southport Inquiry
Mental health access for alcohol addiction
Independent review of use of force on mentally ill detainees
Brook House Inquiry
Mental health access for alcohol addiction
Resolve paramedic-driver shortage in mass casualties
Manchester Arena Inquiry
Chronic healthcare staff shortages
Review embedding doctors with firearms teams
Manchester Arena Inquiry
Chronic healthcare staff shortages
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.